Spencer, Rachel A.
(2019)
Information flow in general practice: investigating the processing of discharge summaries to improve patient safety.
PhD thesis, University of Nottingham.
Abstract
Discharge summaries are an essential tool for communicating patient information from secondary care to general practice on hospital discharge. Although there has been extensive research into their design and completion in secondary care very little is known about primary care perspectives on the processing of these documents. There is a need for greater understanding of the epidemiology of primary care patient safety in order to learn from current actions and processes and generate solutions to prevent future harm.
This study explored a high risk patient population of patients aged 75 years and older who had experienced emergency hospital admission. The study had two main aims. The first aim was to investigate failures in processing actions requested in hospital discharge summaries and sequelae for elderly patients. Aim 1 was met by achieving four objectives which included: estimating the rate of failures in processing actions requested in hospital discharge summaries; estimating the rate of subsequent harm and determining factors associated with these failures. The second aim was to explore staff perceptions of the factors associated with failure to respond to actions requested in discharge summaries and what practices do to mitigate this. Aim 2 was met by achieving five objectives related to an interwoven field work and interview process informed by data from aim 1. The five objectives were: to explore practice’s administrative and clinical processing systems in relation to discharge summaries; construct practice-specific process maps; produce individual practice reports; discuss these reports and process maps with general practice staff in an interview setting and then allow staff to describe existing strategies for safety improvement and generate new strategies within the interview.
The quantitative part of the study was a retrospective records review undertaken after exploration of administrative systems at practice sites. The study population was emergency admissions for patients aged ≥75 years, drawn from 10 general practices in three areas of England. One General Practitioner (GP) researcher reviewed the records for 30 patients at each of 10 practices (n=300) after hospital discharge to determine the rate of adherence to the actions requested in the discharge summary and to estimate the rate of associated harm from non-adherence. Where GPs documented decision making contrary to what was requested, these instances were not classed as failures. Data were also collected on time taken to process discharge communications. The qualitative part of the study consisted of 20 semi-structured, audio-recorded interviews with general practice staff. Interviews were conducted with one practice manager and one GP at each of the 10 practices sampled purposively for the quantitative part of the study. Anonymised data from the quantitative part of the study (including harm vignettes and process maps for their practice) were presented to participants in advance of interviews to stimulate discussion.
There were failures in processing at least one action requested in 46% (112/246) of discharge summaries (95% CI 39-52%). It is important to note that a proportion of ‘failures’ may represent considered, but undocumented, decisions taken by GPs. Medication changes were made as requested in the majority of instances but were not made in 17% (124/750) of requests (95% CI 14-19%). Tests were not completed for 26% of requests (95% CI 16-34%) and 27% of requested follow-ups were not arranged (95% CI 20-33%). Although this does mean, again, that the majority of requests are acted upon. There were 23 harms associated with these failures. Three patients suffered two harms each, therefore the harm rate per patient is 8% (20/246). This equates to a Number Need to Harm (NNH) of 13, showing that harms are relatively frequent in this high risk group. Harms were, on average, of moderate severity and moderate preventability. Increased risk of failure to process test requests was significantly associated with the type of clinical IT system and male patients. Other factors associated with failures included: newly started medicines, delay in uploading the discharge summary to the electronic record and reconciliation of cardiovascular medications. From the quantitative data it is difficult to make conclusions about the causality of failures and this is why the qualitative elements of this study were deemed important. From the qualitative work, five themes developed which describe the journey of the discharge summary and shed light on the causes of failures. Secondary care factors describe participants’ perspectives on creation of discharge summaries and included subthemes relating to the design of discharge summaries, to delegation, to safety of information transfer and to pressures within the wider NHS. Safety features of processing systems collates participants’ thoughts on document handling in primary care. Subthemes included: continuity of care, team-working, protocols, training/staffing issues and workflow targets. The third theme has a specific focus on how medicines reconciliation is managed and included subthemes relating to: communication with patients, medicines related factors, patient vulnerability factors and changing responsibility for prescribing. Error and harm as a result of failure to process discharge summaries describes ‘human error’ and other factors that participants believed contributed failure to respond to requested actions (particularly time pressures and workload). Finally, strategies for safety improvement describes initiatives, both implemented and hypothetical, to prevent failure to adequately process discharge summaries. Examples include: changes to administrative systems, use of information technology as a patient safety aid and national schemes such as the unplanned admissions scheme.
Failures occurred in the processing of requested actions in almost half of all discharge summaries, and with all types of action requested. Associated harms were not uncommon in this high risk group and most were of moderate severity. Practice staff are aware of the importance of accurate and timely processing of requests on discharge summaries, and the potential for error. Strategies are recommended to mitigate against faults in processing discharge summaries including a list of ‘Always Events’® to enable the development and prioritisation of interventions.
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